This document is a passport application form for an Indian citizen seeking a Police Clearance Certificate (PCC). It requests personal details of the applicant such as name, date of birth, address, passport information, and details of parents/guardian. The applicant consents to sharing their Aadhaar information for authentication purposes. The form also asks if the applicant has any pending criminal cases or convictions and requires a self-declaration of citizenship and allegiance to India.

1. Page 1 of 2
I agree Yes No
Applicant Details
Family Details (Father/Mother/Legal Guardian details; at least one is mandatory.) *
GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS
PCC APPLICATION FORMS
Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS.
Furnishing of incorrect information/ suppression of information would lead to rejection of the application and would
attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original documents at the
time of submission of the form. All fields marked with (*) are mandatory to fill.
Passport Number *
Date of Issue (DD/MM/YYYY) * Date of Expiry (DD/MM/YYYY) *
Place of Issue *
Region/Country for which PCC is required *
Purpose for which PCC is required*
Applicant's Given Name (Given Name means First name followed by Middle name (if any))(Initials not allowed) *
Surname
Date of Birth (DD/MM/YYYY) *
Village or Town or City *
Gender * Marital Status * Citizenship of India by *
Employment Type *
Educational Qualification *
PAN (If available)
Voter ID(If available)
Aadhaar Number
I, the holder of above mentioned Aadhaar Number , hereby give my consent to Passport Seva to obtain my Aadhaar Number, Name and
Fingerprint/Iris for authentication with UIDAI. I have no objection using my identity and biometric information for validation with Aadhaar
(CIDR) database only for the purpose of authentication.
Father's Given Name (Given Name means First name followed by Middle name (if any))(Initials not allowed)
Surname
Mother's Given Name (Given Name means First name followed by Middle name (if any))(Initials not allowed)
Surname
S1578477
25/05/2018 24/05/2028
TIRUCHIRAPALLI
Japan
TMSA 3
BALAMURUGAN
PACHAMUTHU
22/05/1989
PUDURPALAYAM,LALGUDI(TK)TIRUCHIRAPALLI
MALE MARRIED
TAMILNADU
TAMILNADU
SEAFARERS
SSLC
BMRPB5771R
YJV0082628
400530350982
PACHAMUTHU
KARUPUDIYAR
RANI
KARUPAIYA

2. Page 2 of 2
Present Residential Address Details
VALIDATE & SAVE
Legal Guardian's Given Name (Given Name means First name followed by Middle name (if any))(Initials not allowed)
Surname
House No and Street Name *
Village or Town or City *
State/ UT *
District *
Police Station *
PIN * Mobile Number * Telephone Number
E-mail ID*
Do you have a Permanent Address? * Yes No
1) Provide the following details if there are any criminal proceedings pending against the applicant.
Are any proceedings in respect of an offence alleged to have been committed by you pending before a
criminal court in India? *
Has any warrant or summons for your appearance been issued and pending before a court under any
law for the time being in force? *
Yes No
Yes No
Has a warrant for your arrest been issued by a court under any law for the time being in force? * Yes No
Has an order prohibiting your departure from India been made by any court? * Yes No
2) Provide the following details if the applicant has been convicted by a court in India.
Have you, at any time during the period of 5 years immediately preceding the date of this application, been
convicted by a court in India for any offence involving moral turpitude and sentenced in respect thereof to
imprisonment for not less than two years?*
Yes No
NOTE:
Applicants are required to submit the proof of address of the present address only, irrespective of the date from which he/she has been
residing at the given address.
Place * Date (DD/MM/YYYY) *
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of
any other country. I have not lost, surrendered or been deprived of the citizenship of India. I have not contravened any of the
conditions relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing
any material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my
application for an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. I
am liable to be penalized or prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence
to furnish any false information or to suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me
in the form is bonafide.
I agree
Self Declaration
08/04/2022
Other Details
PACHAMUTHU
KARUPUDIYAR
1-110-3 MIDDLE STREET
PUDURPALAYAM (PO) LALGUDI(TK)
TAMILNADU 621711
TIRUCHIRAPALLI
KALLAKUDI POLICE STATION
621711 9952633507
balacook1989@gmail.com
PUDURPALAYAM